Provider Demographics
NPI:1508334541
Name:THORNTON YOUTH VISION, LLC
Entity Type:Organization
Organization Name:THORNTON YOUTH VISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-200-5623
Mailing Address - Street 1:1400 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-2229
Mailing Address - Country:US
Mailing Address - Phone:719-200-5623
Mailing Address - Fax:719-960-2654
Practice Address - Street 1:9674 WASHINGTON ST UNIT 104
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-2160
Practice Address - Country:US
Practice Address - Phone:303-450-0184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000168991Medicaid